New WHO malaria treatment guidelines stress need for diagnosis
GENEVA - Research conducted by the Special Programme for Research and Training in Tropical Diseases (TDR) has contributed to new World Health Organization (WHO) guidelines on the treatment of malaria.
Half of the world's population is at risk from malaria. Almost 250 million cases occur each year, causing 860,000 deaths per year, 85% among children and mostly in Africa.
The Guidelines for the Treatment of Malaria (second edition), produced by WHO's Global Malaria Programme, aim to provide countries with the necessary policy recommendations and tools to ensure that patients with malaria are promptly and appropriately diagnosed and then treated with safe and efficacious medicines that are procured from quality-assured sources.
The main changes from the first edition of the guidelines, published in 2006, are the addition of a new artemisinin-based combination treatment (ACT) to the list of recommended treatments, and the emphasis on testing before treating.
For the first time, the guidelines have a specific section recommending home-based management of malaria (HMM) by trained community members, a strategy developed in TDR. Published studies supported by TDR provided additional evidence that HMM improves access to prompt and effective treatment.
They recommend that pre-referral rectal artesunate - suppositories given to patients too sick to take oral medicine - be included in home-based management where feasible. A large-scale randomized controlled clinical trial coordinated by TDR showed that a single dose of rectal artesunate reduced the risk of mortality and permanent disability among patients in remote communities, effectively buying them time to reach health facilities.
The guidelines also draw on evidence generated by systematic research involving TDR into ACTs for treating uncomplicated and severe malaria.
The guidelines stress the importance of diagnosis. In 2008, just 22% of suspected malaria cases were tested in 18 of 35 African countries reporting. Until now, most clinics had to rely on microscopy, but the emergence of data supporting the good performance and heat stability of many commercially available rapid diagnostic tests (RDTs) means a policy change is possible. Many of these tests can reliably demonstrate the presence or absence of malaria parasites in the blood and can be performed at all levels of the health system, including community settings.
TDR is helping malaria endemic countries to improve the quality of their testing services using RDTs. Last year TDR, the WHO Regional Office for the Western Pacific and the Foundation for Innovative New Diagnostics (FIND) conducted the largest ever independent laboratory-based evaluation of RDTs, revealing wide variations in quality and reliability of tests on the market. A second round of performance evaluations is being finalized, and the results are scheduled to be released on World Malaria Day April 25. The goal is to help countries make more informed choices on the purchase and use of RDTs from dozens of commercially available tests.
The move towards universal parasitological confirmation of malaria is a critical step forward in the fight against malaria as it will allow for the targeted use of ACTs for those who actually have malaria. The aim is to reduce the emergence and spread of drug resistance and to help identify patients who have fever but do not have malaria, so that alternative diagnoses can be made and appropriate treatment provided. Therefore, better management of malaria has a positive impact on management of other childhood illness and overall child survival.
At the same time as the new treatment guidelines, WHO also released the first ever procurement guidelines for antimalarial medicines.